1. Field of the Invention
The present invention relates generally to methods, apparatus and kits used for protecting a body tissue which is adjacent to a target tissue undergoing thermal treatment. Particularly, the present invention relates to the protection of the adjacent body tissue from penetration and/or thermal effects by a tissue penetrating thermal device. More particularly, the present invention relates to an interface shield used to protect body tissue adjacent to target tissue from the possible effects of using a radiofrequency electrosurgical apparatus to treat tumors in the target tissue.
The delivery of radiofrequency energy to target regions or target tissues within solid tissue is known for a variety of purposes. Of particular interest to the present invention, radiofrequency energy may be delivered to diseased regions in target tissue for the purpose of causing tissue necrosis. For example, the liver is a common depository for metastases of many primary cancers, such as cancers of the stomach, bowel, pancreas, kidney, and lung. Electrosurgical probes for deploying multiple electrodes have been designed for the treatment and necrosis of tumors in the liver and other solid tissues. See, for example, the LeVeen(trademark) Needle Electrode available from RadioTherapeutics Corporation which is constructed generally in accord with U.S. Pat. Nos. 5,858,740; 5,855,576; 5,827,276 and international patents WO 96/29946 and WO 98/52480. The probes described in these patents comprise a number of independent wire electrodes which are extended into tissue from the distal end of a cannula. The wire electrodes may then be energized in a monopolar or bipolar fashion to heat and necrose tissue within a defined volumetric region of target tissue. In general, the larger the volume treated, the more wire electrodes are necessary to ensure homogeneity of treatment.
Of particular interest to the present invention, as recognized by the inventor herein, use of the multiple electrode arrangements in treating tumors which lay near an adjacent tissue structure requires particular care. For example, as illustrated in FIG. 1, a tumor T deep in the liver LVR may be close to a back or side surface S of the organ, adjacent to the diaphragm D and/or surrounding lung LNG. It may be desirable to access such a tumor T through an entry site E which is opposite this surface S, or at a location which is a considerable distance away from this surface S. A needle electrode 10 may be inserted through the entry point E, traverse healthy liver LVR tissue and be placed within or near the tumor T to be treated. However, if the tumor T is mistargeted, the needle electrode 10 may be misplaced, allowing the electrode tips 12 to protrude and traverse the surface S. Thus, the tip of the needle electrode 10 or the subsequently deployed electrode tips 12 may punch into or through the diaphragm D and possibly into the lung LNG. Such exposure of the electrode 10 or needle tips 12 outside of the liver LVR is disadvantageous in a number of respects. Beyond simple puncture damage, the presence of active electrodes outside of the confinement of the organ being treated subjects other tissue structures of the patient as well as the treating personnel to risk of accidental contact with the electrodes. This may directly destroy healthy tissue in the surrounding organs and tissues or it may cause heat damage. Moreover, the presence of all or portions of particular electrodes outside of the tissue being treated can interfere with proper heating of the target tissue and fail to destroy all or part of the tumor.
As illustrated in FIG. 2, a tumor T in a similar location near a surface S may likewise be accessed through an entry point E which is opposite to this surface S. Even if the tumor T is not mistargeted and the needle electrodes are properly placed within the tumor T such that they do not protrude outside of the liver LVR, surrounding tissue may still be damaged. Heat emanating from the tissue surrounding the electrode tips 12 may raise the temperature of additional non target tissues within a given radius via conduction, as illustrated by a dashed outlined area A. Some tissue in area A may be more fragile or thermally sensitive than the target tissue being treated. Thus, such tissue may be raised to a damaging or lethal temperature during the treatment of a surface tumor in an adjacent organ.
Electrosurgical treatment of such tumors within body organs often involves applying radiofrequency energy in a monopolar fashion where the treatment current travels between the treatment electrode and a dispersive or counter electrode disposed on the patient""s skin. Such an electrode deployment is designed to disperse the energy, as much as possible, as distance increases from the treatment electrode in order to avoid local heating in unwanted locations. This is typically accomplished by designing the dispersive electrode to have a much larger surface area relative to the treatment electrode so that the current density is rapidly dispersed over a correspondingly larger area of tissue. However, despite proper surface area ratios of the treatment electrode to the dispersive electrode, placement of such a dispersive electrode on the outside of the patient""s body may not optimally direct the dispersed energy flow through the tissues surrounding those targeted for treatment. Current flow will follow the path of minimal resistance, partly determined by the shortest distance between the treatment and dispersive electrodes. Thus, sufficient energy delivery to the treatment site may also inadvertently damage healthy tissue located between the treatment site and the dispersive electrode on the outside of the body.
For all of these reasons, it would be desirable to provide improved methods and systems for treating tumors within an organ or tissue, particularly those located adjacent to other tissue structures which are at risk of injury. It would be further desirable to provide such improved methods and systems which would protect surrounding tissue from thermal damage. It would also be particularly desirable if such methods and systems could lessen the risk of accidental penetration of a treatment device into adjacent tissue structures. It would be further desirable if the methods and systems could enhance and make more predictable the uniform treatment of the entire tumor mass, including those portions which lie near the surface of the organ being treated. Finally, it would be desirable to avoid excessive heating and the passage of excessive current through non-target tissues by providing the shortest path between active and dispersive electrodes. At least some of these objectives will be met by the invention of the present application.
2. Description of the Background Art
U.S. Pat. Nos. 5,868,740; 5,855,576; 5,827,276 and international patents WO 96/29946 and WO 98/52480 describe an electrosurgical probe having deployable electrode elements of the type described above. The LeVeen(trademark) Needle Electrode constructed in accordance with the teachings of the above named patents is available from RadioTherapeutics Corporation, assignee of the present application, and is illustrated in brochure RTC 002 published in 1998. Other electrosurgical devices having deployable electrodes are described in German Patent 2124684 (Stadelmayr); U.S. Pat. Nos. 5,472,441 (Edwards et al.); U.S. Pat. No. 5,536,267 (Edwards et al.); U.S. Pat. No. 5,728,143 (Gough et al.); and U.S. Pat. No. 6,050,992 (Nichols); and PCT Publications WO 97/06739; WO 97/06740; WO 97/06855; and WO 97/06857. Medical electrodes having pins and other structures are shown in U.S. Pat. Nos. 3,991,770; Re. 32,066; 4,016,886; 4,140,130; 4,186,729; 4,448,198; 4,651,734; and 4,969,468. A skin surface treatment electrode for the removal of blemishes having a circular array of tissue-penetrating pins is described in Rockwell, The Medical and Surgical Uses of Electricity, E. B. Trent and Co., New York, 1903, at page 558. A cluster electrode comprising a plurality of electrodes projecting from a plate for insertion in tissue is described in WO 99/0410. Another patent of interest includes WO 99/32041 (Kamdar et al).
The present invention provides improved methods, systems, and kits for protecting body tissues which are adjacent to tissues undergoing thermal treatment. Thermal treatment is often prescribed for tumors and other disease conditions within body organs and other tissue masses. The methods, systems, and kits are particularly useful for treating tumors which lie at or near the surface of an organ, such as the kidney, pancreas, stomach, spleen, uterus and particularly the liver. In some situations, such tumors may not be easily accessible through the surface of the organ closest to which they are located. This may be the case when tumors or located along back or side walls of an organ. Thus, it may be desirable to access the tumor through a wall or surface of the organ which is opposite or at a distance from the tumor. One risk of treating such tumors in this manner is the possibility of mistargeting the tumor and penetrating a delivery cannula or portions of a treatment device beyond the surface into the adjacent tissues or organs. In the case of treating the liver, adjacent tissues will most likely include the diaphragm, lung and/or colon. In the case of treating the kidney or uterus, adjacent tissues will most likely include the colon.
During thermal treatment, healthy surrounding tissue may be inadvertently mistargeted and directly ablated. An additional risk, present even when the tumor is correctly targeted, is the possibility of thermal damage to the surrounding, non-targeted tissue. In thermal treatment, heat may dissipate into surrounding tissues which are more fragile and heat sensitive than the tissue in the organ being treated, thus causing unwanted tissue damage. These risks and others may be lessened or avoided with the use of an interface shield between the target region and adjacent body tissues to shield surrounding organs and tissue from treatment effects.
According to the methods of the present invention, a target region of tissue in an organ may be identified and targeted by various imaging means for thermal treatment. Thermal treatment may include the delivery of various types of energy for hyperthermic and/or hypothermic effects. In one exemplary case, radiofrequency energy may be delivered for hyperthermic therapy. Generated heat may necrose tissue in a given area, forming a lesion. Similarly, laser probes and electric cauterizers/resistance heated probes, to name a few, may be used. Alternatively, hypothermic treatment may be delivered by cryogenic probes, for example. Hereinafter, thermal treatment will primarily be described in terms of hyperthermic treatment and the production of heat. However, it may be appreciated that such terminology is not intended to limit the scope of the present invention. Heat, heat transfer, heat absorption, heat conduction, and similar terminology may be understood to include synonymous situations and conditions in hypothermic treatment.
If a target tissue region is sufficiently close to a surface of the organ in which it is located, it may be desired to provide a conformable temporary interface shield between the organ surface and the adjacent tissue to prevent the treatment from damaging the adjacent tissues. The interface shield may be positioned over the surface such that the shield lies between the target region and adjacent body tissues. In the case of radiofrequency treatment, at least one tissue penetrating electrode may then be introduced to the target region in a direction toward the protective interface shield. Any electrodes or portions of the device which penetrate the surface of the organ will be prevented from entering the surrounding tissue due to the presence of the shield. Once the electrode is positioned in a desired configuration, electrical energy, such as radiofrequency or other high frequency energy, may be applied to the target region of tissue through the electrode. The energy may be applied in a bipolar fashion where current flows between separated portions of the electrode or between two separate electrodes. Alternatively, the energy may be applied in a monopolar fashion where the current flows between the treatment electrode and a dispersive or passive electrode. The dispersive electrode is typically disposed on the patient""s skin, however in some cases the protective interface shield may also function as a dispersive electrode as will be further described herein.
In a first aspect of the present invention, the protective interface shield reduces the incidence of at least one of (a) thermal treatment device penetration into adjacent body tissues and (b) heat transfer into adjacent non-targeted body tissues. It may be appreciated that the treatment device may include a delivery device, probe or cannula to position the treatment device in a desired location. The shield is comprised of a flexible planar member having at least a first layer comprising a penetration barrier and a second layer comprising a heat transfer barrier. In the case of electrosurgical treatment, the thermal treatment device may comprise a radiofrequency electrode or needle electrode. In a preferred embodiment, an array of such electrodes may be advanced forwardly from a distal end of a probe or sharpened cannula during placement, so that the electrodes evert outwardly as they are advanced into the target tissue. The penetration barrier may resist penetration by the probe and/or needle electrodes as they are advanced and positioned in the target tissue. Specifically, electrode tips may attempt to penetrate the surface of the organ and advance toward adjacent tissue. However, the penetration barrier may serve to resist tip advancement and/or deflect such a tip in a direction away from the adjacent tissues which are desired to be protected from such treatment. Thus, the penetration barrier may be comprised of any suitable penetration resistant material. Penetration resistance may be measured as toughness by Charpy or Izod according to ASTM D256. Preferred materials have a penetration resistance or toughness equal to or greater than 10 cm-kg/cm (2.0 ft-lbf/in).
Radiofrequency (RF) energy is supplied to the needle electrodes which heat the target tissue for a period of specified time and at a power level sufficient to necrose tissue. Transfer of such heat through the flexible planar member may be reduced by the heat transfer barrier. This may be accomplished with the use of a material which acts as a thermal insulator, providing a passive barrier to conductive heat transfer. Preferred materials may be at least partially hydrophobic or non-hydrophilic so as to maintain such thermal insulation properties in a moist body environment. Such materials may include closed cell or open cell foams. Alternatively, the barrier of heat transfer to adjacent tissue may be accomplished with the use of a material which absorbs heat or acts as a heat sink. Such a heat sink, for example, may provide active cooling as a barrier to heat transfer. This may be provided by a material that can undergo an endothermic phase change or endothermic chemical reaction at or above body temperature. One example of such a material is a frozen medium which melts at body temperature. The frozen medium may be encapsulated in a leak-proof container to prevent loss of medium to the environment. Still further, the heat transfer barrier may be comprised of a material that conducts heat away from the target tissue. This may be accomplished by a metallic sheet. The metallic sheet may preferentially conduct heat away from the tissue targeted with the highest heat concentration. This may be desired to more evenly distribute the generated heat over a wider surface area with increased heat conductivity.
The materials comprising the above described barriers may be arranged in any number of patterns or configurations to comprise the protective interface shield. Such arrangements may include stacked layers or encapsulated layers, to name a few. In some cases, a material may be selected which inhibits both needle penetration and heat transfer for use in constructing the flexible planar member. In such a situation, the first and second layers may be comprised of the same material, essentially forming one layer and providing both functions.
In a second aspect of the present invention, the protective interface shield may provide electrical conductivity, similar to that found in body fluids and tissues. The shield may be comprised of a layer of electrically conductive material in addition to the above described layers and/or functions. Preferred materials may include hydrophilic or at least partially hydrophilic materials. Such a material may comprise a porous substrate capable of absorbing a conductive fluid, such as saline, blood or other body fluids. The electrically conductive layer may be designed to encourage symmetrical dispersion of radiofrequency energy from within the target treatment site. However, it is also desirable that such a layer not be so conductive, as in a metallic layer, so as to cause an undesired preferred current path, leading to lesion asymmetry. To achieve this, the layer should have an electrical conductivity similar to body tissue. In addition, the materials comprising the protective interface shield should be arranged so that the conductive layer is located near the surface of the shield and is placed toward the surface of the target tissue under treatment. It may be appreciated that such a layer may also extend around the interface shield to form an encapsulating layer or jacket.
In a third aspect of the present invention, the protective interface shield may provide a dispersive electrode. The shield may be comprised of a layer providing a dispersive electrode in addition to the above described layers and/or function. As mentioned, when energy is applied to the target tissue in a monopolar fashion, a large dispersive electrode is typically disposed on the patient""s skin. However, such placement may not optimally direct energy through the target tissue and may damage healthy tissue in surrounding areas.
Placement of a similar dispersive electrode within the interface shield may provide a number of advantages. First, the shape and location of the lesion created to engulf a tumor or target tissue may be optimized. For example, an asymmetrical lesion may be created to treat a non-spherical tumor or target tissue. Typically, when a dispersive electrode is placed on the patient""s skin, relatively remote from the treatment site, the treatment electrode creates a symmetrical or spherical lesion centered about the electrode. Although the current travels between the treatment electrode and the dispersive electrode, distance between the electrodes disperses the current and creates asymmetrical lesion. By utilizing an interface shield having dispersive electrode layer, the treatment current will preferentially travel between the treatment electrode and the close proximity electrode layer within the shield. The resulting lesion will extend toward the shield and will be ellipsoidal or cylindrical, rather than spherical. In some cases, the dispersive electrode layer may eliminate the need for an external dispersive electrode placed on the patient""s skin. Second, use of a shield containing a dispersive electrode in combination with one or more standard skin placed dispersive electrodes may result in a higher proportion of the electrical output used to heat tissue in the target region and less energy dissipated into surrounding non-target tissue. Here the dispersive electrode layer, when connected to a current source in parallel with a dispersive electrode on the surface of the body of the patient, may reduce the total impedance of the system so that a higher proportion of the electrical output becomes usable to heat the target tissue.
The dispersive electrode layer comprises a material that provides a higher level of conductivity than either body tissue or any other electrically conductive layer which is part of the shield. This provides a more preferential path for dispersion of applied energy. It is not required that the dispersive electrode layer directly contact body tissue, and in fact such contact would be undesirable. Construction of the dispersive electrode layer in the form of a capacitor may provide a low impedance energy return without the possibility of a xe2x80x9cshort-circuitxe2x80x9d caused by contact with the treatment electrode. Capacitive coupling of the radiofrequency energy to this dispersive electrode tends to spread the RF current over a wider surface than if it were in direct tissue contact. This may allow the user to maintain a higher level of current in the target tissue region while reducing the risk of creating a xe2x80x9chot spotxe2x80x9d or increased level of tissue damage between the treatment electrode and the shield surface.
The materials comprising the above described functions may be arranged in a number of patterns or configurations to comprise the protective interface shield. Such arrangements may include stacked layers or encapsulated layers, to name a few. It is preferred that material comprising a heat transfer barrier, as described above, be positioned as a layer between the dispersive electrode layer and the surrounding non-target tissue. Typically, materials which provide a barrier to heat transfer also provide electrical insulation. Thus, such a layer may act to further protect the shielded tissue from both damage due to conducted heat and damage due to radiofrequency current heating. It is preferred that material comprising a dispersive electrode layer, as described above, also be positioned as a layer between the heat transfer barrier and the penetration barrier, both of which being non-conductive will isolate the dispersive electrode from direct tissue contact. Such a shield will typically be positioned in the body so that the above described layers are placed in the following order from the target tissue outward toward the adjacent non-target tissue: penetration barrier, dispersive electrode layer, heat transfer barrier. This may protect the dispersive electrode layer from the possibility of penetration or contact by the treatment electrode placed within the target tissue, and may simultaneously protect the adjacent non-target tissue from excessive thermal damage. A conductive layer, described previously, may also be present between the penetration barrier and target tissue or fully encapsulating the shield, however it is not essential in this configuration.
In a fourth aspect of the present invention, the protective interface shield may have a surface finish, coating or layer to provide desired surface characteristics for specific purposes. Such a surface layer may be non-sliding to minimize movement between the shield and the contacting tissue. This may be useful when placed against the target tissue organ to retain the shield in position. Suitable materials may include a gauze or a felt. Alternatively, the surface layer may be slippery or provide a low friction interface between the shield and the contacting tissue. This may be useful for contact against adjacent tissues which may move relative to the shield so that such tissues may slide with reduced irritation or frictional damage. In a preferred embodiment, an interface shield may be comprised of a surface layer on each side of the planar member with opposite characteristics, e.g. with a non-sliding surface against a stationary target organ such as the liver, and a low friction surface against an adjacent tissue such as the diaphragm, which moves with respiration. The above described surface characteristics may also be provided by any of the previously described layers of the interface shield providing functions related to other aspects of the present invention. For example, the conductive layer has been described as being located on the surface of the interface shield to be placed against the target tissue. This layer may be comprised of a rough textured hydrophilic fabric which may also serve as non-sliding surface coating to hold the shield in position. Likewise, the heat transfer barrier has been described as being located on the surface of the interface shield, particularly for placement against the adjacent, non-targeted tissue. The heat transfer barrier may be comprised of a material which enhances movement between the shield and the adjacent tissue, such as a smooth polyethylene foam or a heat absorbing or conducting material coated with a hydrophilic material. Thus, surface layers may be multi-functional.
In addition, it may be appreciated that multiple interface shields may be used during treatment of a target tissue. It may be desired to position one shield over the surface of the target tissue to protect adjacent tissue. At the same time, shields may also be positioned over tissues that are not immediately adjacent the surface of the target tissue but are within an area of the target tissue that may be injured from the thermal treatment. This may provided added protection for surrounding tissues, specifically particularly susceptible or sensitive tissues. Such individual shields may have an area in the range from 50 cm2 to 300 cm2. It is also possible to use more than one shield in any given location, such as in a stacked configuration, to provide possibly additional protective effects, or by interlocking with adjacent shields to protect additional contiguous tissue area.
The methods and devices of the present invention may be provided in one or more kits for such use. The kits may comprise at least one interface shield and instructions for use. Optionally, such kits may further include additional shields. Each shield may be designed for placement in specific locations, for contact with specific tissues or to provide specific functions. Alternatively, a number of shields may be provided for positioning in numerous locations; such shields may be capable of interlocking to cover a larger surface area, or they may be stacked or layered in one location. Optionally, such kits may further include a tissue penetrating electrode and any other materials or items relevant to the present invention.